Satellites offer substantial promise in many areas of “electronic health” or eHealth, defined as the use of information and communication technology in the health sector, including digital data transmis-sion, storage and retrieval, for clinical, educational and administrative purposes (WHO, 2002; Dzenowagis, 2004). The discipline of eHealth can be of use in the most precise area of medicine as well as help solve medical problems and boost training in remote areas of Africa. In the UK, for example, young surgeons simply don’t have time to attend training courses or leave their hospitals to observe new surgical techniques or investigate new tech-nologies. Within hospitals, shift rotas prevent most trainee surgeons from attending regularly-scheduled instruction sessions, making flexible training pro-grammes absolutely essential. A pilot project called Telematic Training for Surgeons (TETRASUR), ini-tially a collaboration between the University of Plymouth and the European Space Agency (ESA), funded by regional medical research grants and industry sponsorship, was established in 1997 to investigate telematics applications with respect to surgeon training, initially in local hospitals (Kingsnorth et al., 1999).
The TETRASUR project metamorphosed into the Satellite Network Telematics Training for Surgeons (SANTTSUR), following receipt of a £300,000
research grant from the ESA, as a distance learning package integrating live digital TV, video conferenc-ing and the internet, with a service beconferenc-ing provided to 26 nationwide locations. SANTTSUR delivered high-quality, live, interactive TV programmes to hospitals and medical centres broadcast from a stu-dio in Plymouth via a TDS4b uplink provided by the ESA and received by sites throughout the UK and Ireland. The course material was modular, built on a syllabus devised by the Royal College of Surgeons (RCS). Telematic-based training enabled tutors and trainees to remain in their local hospitals and con-duct training in close proximity to their patients. Trainees could interact with tutors, presenters and contributing experts via real-time phone, text-mes-saging, e-mail, fax and ISDN (Integrated Services Digital Network) video conferencing. Many hospi-tals, clinics and medical facilities already have con-siderable infrastructure in video conferencing and telecommunications, and reception merely required an additional small, cheap antenna, 1.2 m in diam-eter. Three sets of 10 lectures, were transmitted weekly via a single 90-minute lunchtime session. Each transmission comprised formal presentations, studio discussion, live ISDN6 video feeds from teaching hospitals and trainee question-and-answer sessions via ISDN2, telephone or on-line chat. A noteworthy “Case of the Week” was also included. Broadcasts could also be videotaped, and then made available at any time for the trainees. In several institutions, a consultant would assign a task based on the broadcast, with a written response required within a set time. A general review and open forum Corresponding author:
Andy Crump, Visiting Professor Kitasato University, 5-9-1 Shirokane Minato-Ku, Tokyo 108-8642, Japan E-mail: crumpa@easynet.co.uk
Satellite teleHealth: good for the cutting edge and in the
bush?
Andy Crump
Kitasato University, Shirokane, Minato-Ku, Tokyo 108-8642, Japan
Keywords: satellite health, mrcsTV, surgeon training, African eHealth, satellite training.
session could also be held at the end of each term (Vranch and Kingsnorth, 2001). Technically, ISDN6 proved good for dealing with visual content, although ISDN2 was not so good for handling real-time question and answer sessions. For interaction, text messaging emerged as the most popular medi-um.
SANTTSUR subsequently evolved into mrcsTV, once critical matters of administration, dissemina-tion, expansion, accreditation and sponsorship were resolved. The new entity, operated by the University of Plymouth, ESA, RCS and Plymouth Enterprise Partnerships Ltd, became an education and training programme aimed at individuals studying for exam-inations of any of the four Royal College of Surgeons in the UK or Ireland, as well as being high-ly useful for those studying for similar qualifications abroad. Subscriptions were provided by registered centres and from individuals, with broadcast being supported by a dedicated website learning portal. Thus mrcsTV became a successful integration of satellite and telematics technology, video conferenc-ing and rapidly-developconferenc-ing internet learnconferenc-ing portals. Live broadcasts were reworked for dissemination via a dedicated multimedia website and supported by course information, downloadable materials and links to other relevant sites. Once operational, the entire system also became useful for other educa-tional activities. The mrcsTV adequately met specif-ic local needs by providing high-quality, structured, consistent learning and materials at the workplace. It saved time that would otherwise be lost through traveling to learning establishments. Synchronization of training at several locations also facilitated better sharing of expertise. The project demonstrated successful use of MPEG2 satellites as the ideal delivery platform (satellites can handle higher-definition images than the internet) and showed that the system was very viable.
The success of the mrcsTV model was mirrored in another ESA-supported project, called Mayflower, which used satellites to deliver university courses in medicine to students and nurses in Norway and Italy. Perhaps the most sophisticated of ESA projects
was Multimed, in which satellites were used to allow trainees to not only watch live operations, but also to carry them out by remote control. A prone patient, nicknamed “Stan the Man”, was the Guinea pig for all manner of medical procedures. His heartbeat pulse and breathing were normal, and when an incision was made, blood flowed. However, Stan was a high-tech robotic patient, his life-like characteristics controlled by a Human Patient Simulator computer, allowing students, physicians and medical support staff to familiarize themselves with real-life clinical scenarios without endangering life.
The main constraints in satellite-based operations such as mrcsTV are related to sources of funding (donations, subscription, sponsorship, course fees, registration fees, etc). In addition, the cost of TV studios and broadcast infrastructure can be prob-lematic. The collaboration of experts, accreditation and licencing also pose significant challenges. However, the overwhelming threat proved to be the accelerated progress made in on-line systems and software programmes, especially with regard to streaming video, coupled with internet access (par-ticularly the problem of firewalls), causing mrcsTV to cease broadcasting in 2005.
TETRASUR and the subsequent mrcsTV were successful initiatives that addressed an identified need with an innovative solution. Success was built on the provision of resources (from the ESA), the unbridled enthusiasm of a few key individuals, engagement of committed, already-overworked sur-geons, and a regional focus to demonstrate a poten-tial national-level scale-up. However, changes in key personnel proved devastating in a time-sensitive operation. Internet video streaming products cou-pled with mainstream, heavily-sponsored and gov-ernment-led internet-based enterprises, such as HealthExecTV (http://www.healthexectv.tv), then basically excluded the use of satellites to provide this type of service, especially as all potential users have internet access (Vranch, 2005). Nevertheless, the success of mrcsTV, and the very factors that stimulated its demise, indicate that the well-proven A. Crump - Geospatial Health 1, 2006, pp. 7-10
system could be a much-needed and viable “leapfrog” solution, especially for Africa.
The use of satellites in health commenced with the INTELSAT-sponsored Satellites for Health and Rural Education (SHARE) project during 1985-1987, when free satellite capacity was made avail-able to test rural and remote educational and tele-health projects globally. Indeed, China began its educational TV activities, which now reach millions of viewers in remote areas, as part of SHARE. Today, with almost universal access to the internet in developed nations, the use of satellites is compar-atively expensive and less integrated with other resources, the internet being much more user-friend-ly and accessible. However, satellite communication (Satcom) remains a technology with unique charac-teristics of reach, performance and flexibility. It can deliver bandwidth exactly where there is a need, completely independent of pre-existing terrestrial infrastructure or geography, creating broadband communication as a self-contained solution. Admittedly, Satcom-based access to the internet is expensive, around 5 times greater than normal ter-restrial access via ADSL. But this is not the case in developing countries, where many parts - especially rural areas - remain ‘unwired’. Moreover, such areas cannot be connected economically using other tech-nologies. In these circumstances, Satcom offers the prospect of supplying audiences with the same qual-ity of service that is provided in urban areas, in a cost-effective manner. Furthermore, the technology is available now and, increasingly, infrastructure is being provided free of charge through both the pub-lic and private sectors.
In Africa, 54 countries have access to the internet, but most use VSAT for internet access. As increas-ingly more fibre optical cables are laid (e.g. the $1.8 billion AfricaONE cable which will encircle the con-tinent) commercial broadband access in capital cities and some coastal towns will increase - at a high cost to national governments and, subsequent-ly, users. Yet much of the rest of the continent will continue to have inadequate communications infra-structure, meaning that satellites will remain the
best means to broadcast radio, video and data files for many years to come.
In the public sector, the International Telecommunications Satellite Organization (ITSO) has launched the Global Broadband Satellite Infrastructure Initiative (GBSIi) as part of the WSIS Action Plan. The GBSIi will help overcome “digital divides” and redress the unequal distribution of connectivity between countries and regions, and between urban and rural areas. In Africa, the Regional African Satellite Communications Organisation (RASCOM), consisting of 44 country members, will belatedly launch its first dedicated satellite in mid-2006. Established in 1993, RAS-COM aims to provide all Africa with efficient and inexpensive telecommunications facilities and meet all radio and television requirements, using all avail-able technologies. The new satellite will cover the entire continent, providing overlapping beams in the Ku-band and a single C-band in a fully-integrated network. One of RASCOM’s objectives is to ensure that satellite-based infrastructure serves all rural areas. The high-power Ku-band necessitates only small diameter, low-cost, easily-erected ground ter-minals, offering universal access to 700 million peo-ple, especially those in remote communities.
In the private sector, various organisations are providing ‘satellite philanthropy’ as exemplified by the WorldSpace Foundation, which donates 5% of space on the three WorldSpace Corporation satel-lites to non-commercial, social development ven-tures. In 2000, WorldSpace and Satellife (an inter-national not-for-profit organization devoted to improving health using electronic communications) combined to launch the Public Health Channel for Africa. Initially, receivers will be located in health facilities, medical schools, ministries and research institutes in four countries (Ethiopia, Kenya, Uganda and Zimbabwe), the service later expanding to other countries as funds become available.
The only institution currently providing world-class multimedia products to the entire African con-tinent is the World-Bank-sponsored African Virtual University (AVU). Similar to the mrcsTV model, the A. Crump - Geospatial Health 1, 2006, pp. 7-10 9
AVU uses an interactive process that allows students – even those in remote and isolated areas – to engage in real-time discussions with experts in Africa and overseas in a manner that has proved sustainable, although the AVU signal is currently up-linked from Washington, DC. (Strehler, 2002).
As an indicator of the promise and potential that Satcom has in Africa, UNESCO has recently part-nered with WorldSpace (operator of the AfriStar™ satellite) to demonstrate and test the potential of digital radio to deliver low-cost, effective multime-dia-based and real-time distance education and information to rural areas, continent-wide. Three Community Multimedia Centres (CMC) in each of five countries (Ethiopia, Namibia, Tanzania, Uganda and Zambia) will be provided with digital radio receivers, data interfacing equipment and technical support. At least one of the CMCs will have internet connectivity, and one will be either a school, a training facility or a policy-formulation institution promoting Information, Communication and Training (ICT) for development. Up to 30 addi-tional centres, NGOs or development agencies in Europe, those capable of receiving and decoding the Afristar signal, will also participate. Experts from Africa and from overseas will give live lectures with real-time interactive feedback.
On the ground, the African Medical and Research Foundation (AMREF) has already introduced a prac-tical telemedicine project, providing long-distance medical advice via an audio-visual satellite link to doctors in remote desert towns in northern Kenya, and on the shores of Lake Victoria. Meanwhile, in the Schools-based Telecenter (SBT) project in Uganda, a
national satellite network set up as part of the World Links initiative of the World Bank Institute and the World Links NGO (http://www.world-links.org), a much more basic problem is being addressed. The project, supported by the Bill and Melinda Gates Foundation, is investigating the use of solar energy to power the systems in rural areas where electricity sup-ply is either unreliable or non-existent and generators are too expensive.
References
Dzenowagis J, 2004. Global eHealth Strategy Draft for Consultation. World Health Organization, Geneva. Kingsnorth A, Campbell J, Vranch A, Wheeler S, 1999. The
digital surgeon: Delivering training through telematics. Poster presented at the 19th World Conference on Open Learning and Distance Education, Vienna, Austria (June 20-24).
Strehler A, 2002. Mapping public health education capacity in and for Africa. Executive Summary. Afrihealth (down-load from, http://www.afrihealth.up.ac.za/reports/exec% 20summary.PDF).
Vranch AT, 2005. Integrated satellite TV, videoconferencing and Internet video in distance training for surgeons: Experiences and strategic development of mrcsTV. Paper presented to the 5th International DIVERSE Conference, Vanderbilt University, Nashville, Tennessee, USA, (5-7 July, 2005).
Vranch AT and Kingsnorth A, 2001. Surgeon training via video conferencing and the internet. Proceedings of the IEEE International Conference on Advanced Learning Techniques (ICALT’01).
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